A client has a sodium level of 121 mEq/L. What is the priority nursing intervention?

Choice A reason: Measuring arm circumference quantifies swelling, a sign of complications like thrombosis or infection. Comparing both arms establishes a baseline, aiding in assessing edema severity. This objective data guides interventions, prioritizing assessment before invasive actions, ensuring accurate diagnosis and management of PICC-related issues like venous thrombosis.

Choice B reason: Notifying the provider is important but not the first step. Measuring arm circumference provides objective data to report accurately. Swelling may indicate thrombosis or infection, but without measurements, premature notification lacks specificity, potentially delaying interventions based on clinical findings and diagnostic confirmation.

Choice C reason: Removing the PICC line is premature without confirming the cause of swelling. Thrombosis, infection, or mechanical issues could cause swelling, but removal risks complications like bleeding. Assessment, like measuring arm circumference, is needed first to determine if removal or other interventions are warranted.

Choice D reason: Applying a cold pack may reduce swelling but does not address underlying causes like thrombosis or infection. Without assessing the extent and cause of swelling, this intervention is inappropriate as a first step. Objective data collection, like measuring arm circumference, guides effective treatment and prevents complications.

Choice A reason: Eating breakfast before surgery indicates a need for further teaching, as fasting (nothing by mouth) after midnight prevents aspiration during anesthesia. Food intake increases gastric contents, risking pulmonary complications, making this a critical misunderstanding requiring correction to ensure safe surgical preparation.

Choice B reason: Receiving an antibiotic preoperatively is standard to prevent surgical site infections, especially in high-risk procedures. This statement reflects correct understanding, as prophylactic antibiotics reduce bacterial load, minimizing postoperative infection risk, indicating no need for further teaching on this point.

Choice C reason: Refraining from smoking 8 hours before surgery is appropriate, as smoking increases airway reactivity and secretions, risking respiratory complications. This shows understanding, though longer cessation is ideal, making further teaching unnecessary for this specific preoperative instruction.

Choice D reason: Showering with Hibiclens (chlorhexidine) the morning of surgery is correct, as it reduces skin bacterial load, lowering infection risk. This statement reflects proper understanding of preoperative skin preparation, indicating no need for further teaching on this aspect of surgical preparation.